Imaging of posterior ankle pain : Main etiologies and differential diagnosis

Transcription

1 Imaging of posterior ankle pain : Main etiologies and differential diagnosis Poster No.: C-2399 Congress: ECR 2017 Type: Educational Exhibit Authors: W. Frikha, M. MECHRI, S. boukriba, H. RIAHI, M. CHELLI BOUAZIZ, M. F. Ladeb; Tunis/TN Keywords: Diagnostic procedure, Ultrasound, MR, Conventional radiography, Musculoskeletal soft tissue, Musculoskeletal joint, Musculoskeletal bone, Acute DOI: /ecr2017/C-2399 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 36

2 Learning objectives The aims of this pictorial review article with case reports is to describe different causes of posterior ankle pain, to describe diagnostic imaging strategies of these pathologies, and illustrate their imaging features, including relevant differential diagnoses. Certain key findings on conventional radiography (CR), multidetector computed tomography (MDCT), ultrasonography (US), magnetic resonance imaging (MRI) leads to specific diagnoses. Background Posterior ankle pain presents a diagnostic dilemma for the referring clinician secondary to the non-specific clinical presentation of various ankle diagnoses. It can result from many causes and may represent a diagnostic challenge. Findings and procedure details 1.PAIS Clinical signs and symptoms : Pain at the posterior ankle exacerbated by plantar flexion or dorsiflexion Posterior tenderness anterior to the Achilles tendon. Ankle radiographs should initially be obtained to exclude a possible fracture of the trigonal process Observing irregular margins of the os can suggest a traumatic event Although an os trigonum is usually round or oval with well-defined corticated margins (red arrow ) Fig. 1 on page 6 Fracture of the lateral tubercle has irregular serrated margins between the ossicle and the posterior talus (green arrow ) Fig. 2 on page 7 CT, with its high spatial resolution, may be helpful in evaluating the osseous structures. Fig. 3 on page 8 MRI findings : Page 2 of 36

3 Os trigonum with marrow edema or fluid signal at the synchondrosis(os trigonum Syndrome) Intermediate to low signal synovial thickening at the posterior ankle. Subchondral edema within the distal posterior tibia, posterior talus or posterior process of the calcaneus Fig. 4 on page 9 Fig. 5 on page 10 Possible associated Finding : FHL tenosynovitis What else.? Achilles Tendinopathy : tendinosis, retrocalcaneal bursitis, Haglund deformity FHL tendinitis (stenosing tenosynovitis) Peroneal tendon subluxation, Ankle sprain, Lateral ankle instability Tarsal tunnel syndrome, Osteo chondral lesion of talar dome, Calcaneal fracture, Tarsal coalition 2.Achilles Tendinopathy Achilles tendinosis typically involves the mid portion of the tendon and left untreated, may result in dramatic painful rupture with sudden loss of function Less frequently, the tendinosis may involve the insertion of the Achilles into the calcaneus (known as enthesopathy) Bone oedema Prominence of the calcaneus, known as Haglund's deformity. Ultrasound Thickening and rounding of the affected portion of the tendon Fig. 6 on page 12 The cutoff value of 1 cm in anteroposterior diameter is usually used for diagnosis Fig. 7 on page 12 Page 3 of 36

4 Neovascularisation which, if present, is usually indicative of poorer outcome and more severe clinical symptoms Fig. 8 on page 13 Additional signs include increased Kager's fat pad echogenicity and increase thickening of hypoechoic paratendon Fig. 14 on page 21 MRI : Shows increased intratendinous signal and tendon enlargement Fig. 9 on page 13 Fig. 10 on page 14 +/- oedema in Kager's fat pad anterior to the Achilles tendon ( Fig 11, 12,13 ) 3.Flexor Hallucis Longus tenosynovitis Tenosynovitis most commonly occurs proximally, posterior to the talus, at the level of the sustentaculum talus Symptoms, however, may occur anywhere through-out its course, including the midfoot at the master knot of Henry and distally within the forefoot between the sesamoids at the region of the FHL tendon insertion MRI: excess fluid accumulation within the FHL tendon sheath posterior to the ankle joint Potential pitfall is a normal communication between the FHL tendon sheath and tibiotalar joint that exists in approximately 20% of individuals Fig. 15 on page 21 4.Peroneal tendon subluxation Fig. 16 on page 23 May occur in isolation or in conjunction with anterolateral ankle instability Distinguishing between injuries of these structures and other causes of pain in this region is important in planning appropriate treatment, as peroneal retinacular injuries often require operative repair Dynamic US +++ The dislocation of the tendon is produced by forced eversion of the foot Fig. 17 on page 23 Fig. 18 on page 24 Fig. 19 on page 25 Page 4 of 36

5 5.Tarsal Tunnel Syndrome Fig. 20 on page 26 Fig. 21 on page 27 6.Tarsal Coalition Tarsal coalition is the abnormal union of 2 or more bones in the hindfoot and midfoot This union may be either complete or incomplete, and the condition may be congenital or acquired secondary to trauma, infection, surgery, or articular disorders Coalitions can be bony (synostosis), cartilaginous (synchondrosis), or fibrous (syndesmosis) The 2 most common types: calcaneonavicular and talocalcaneal All calcaneonavicular coalitions can be evaluated by using plain radiographs Fig. 23 on page 28 Talocalcaneal coalitions can be difficult to identify on standard radiographs Fig. 22 on page 29 Cross-sectional imaging with CT or MRI is advantageous for evaluation of complicated cases of tarsal coalition for preoperative surgical planning Fig. 25 on page 31 MRI is particularly useful in depicting non-osseous fibrous and cartilaginous coalitions Fig. 24 on page 30 7.Osteochondral Lesion Fig. 26 on page 32 Osteochondritis dissecans (OCD) is an acquired idiopathic lesion of subchondral bone that can produce delamination and sequestration with or without articular cartilage involvement and instability It will be used to refer to mainly non-traumatic lesions in the child or adolescent The term osteochondral fractures indicates injuries of traumatic origin involving both the cartilage and the subchondral bone and occurring predominantly in adults MRI : Page 5 of 36

6 Osteochondral fragments appear hypointense on T1-weighted images; on T2-weighted images They have a very variable intensity, however they are always characterized by a hyperintense line at their base, which is a sign of the detachment Other rare etiologies of posterior ankle pain Bone Infarction Fig. 27 on page 33 Calcaneus Osteomyelitis Fig. 28 on page 33 Synovial sarcoma Fig. 29 on page 34 Fig. 30 on page 35 Images for this section: Page 6 of 36

7 Fig. 1 Page 7 of 36

8 Fig. 2 Page 8 of 36

9 Fig. 3: Sagittal CT scan image showing an os trigonum (yellow arrow) Page 9 of 36

10 Fig. 4: Sagittal DP Fat Sat MR image showing an os trigonum with bone marrow edema, fluid signal at the synchondrosis and subtalar joint fluid Page 10 of 36

11 Fig. 5: Axial DP Fat Sat MR image showing a FHL tenosynovitis associated with the ostrigonum syndrome Page 11 of 36

12 Fig. 6: Panoramic view of the Achilles Tendon showing thickening of the mid portion of the tendon Page 12 of 36

13 Fig. 7 Fig. 8 Page 13 of 36

14 Fig. 9 Page 14 of 36

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16 Fig. 10: MRI of the previous patient showing fusiform thickening of the Achilles Tendon with interstitial fissural rupture Page 16 of 36

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18 Fig. 11: Achilles Tendinopathy with enlarged tendon and intra tendinous oedema and internal fissural ruptures associated with anterior bursitis caused by Haglund's deformity ( bony overgrowth of the posterior calcaneus) Page 18 of 36

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20 Fig. 12: Achilles Tendinopathy with enlarged tendon and intra tendinous oedema and internal fissural ruptures associated with anterior bursitis caused by Haglund's deformity ( bony overgrowth of the posterior calcaneus) Page 20 of 36

21 Fig. 13: Sagittal DP FS shows fissural rupture of the tendon Fig. 14: US in the long axis of the Achilles tendon showing enthesis ossification in the calcaneal insertion (arrow) Page 21 of 36

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23 Fig. 15: Axial DP FAT SAT weighted image showing the FHL surrounded by focal fluid Fig. 16: The superior peroneal retinaculum (SPR) is attached to the lateral fibular periosteum and forms a fibro-osseous tunnel which restrains the peroneus brevis (PB) and peroneus longus (PL) tendons within the peroneal groove More distally the peroneal tendons have separate fibro-osseous tunnels formed by the inferior peroneal retinaculum (IPR) STADNICK Page 23 of 36

24 Fig. 17: Dynamic US +++ The dislocation of the tendon is produced by forced eversion of the foot Page 24 of 36

25 Fig. 18 Page 25 of 36

26 Fig. 19 Page 26 of 36

27 Fig. 20: It is a compression, or squeezing, on the posterior tibial nerve that produces symptoms anywhere along the path of the nerve running from the inside of the ankle into the foot Page 27 of 36

28 Fig. 21: Coronal and axial CT images of the ankle showing postero medial Talar Fracture and sustaculum tali fracture with tibial nerve impingement (arrow) Page 28 of 36

29 Fig. 23: Lateral radiographs and sagittal CT images in bone algorithm Note the elongated tubular extension of the anterior calcaneus Page 29 of 36

30 Fig. 22: Lateral radiograph of the foot reveals a classic C sign (arrows), which is a Cshaped line formed by the medial outline of the talar dome and the inferior outline of the sustentaculum tali. The C sign is a reliable indicator of subtalar coalition on lateral radiographs. Page 30 of 36

31 Fig. 24: MRI : Coronal and sagittal T1 images showing the fusion of the subtaler joint with solid bone obliterating the joint Page 31 of 36

32 Fig. 25: Sagittal CT scan of the foot in a 10 year old boy showing total fusion of posterior subtalar joint and of cuboid with the lateral Cuneiform Page 32 of 36

33 Fig. 26: 61 year old women with ankle posterior pain Coronal, sagittal and axial CT images showing fragmentation of the talar dome and degenrative arhtitis in tibio-talar and talo- navicular joints Fig. 27: 25 old man with history of drepanocytosis presenting posterior ankle pain Sagittal STIR and T1 gadolinium weighted images show subperiosteal hematoma in the posterior distal tibia peripheral enhancement after Gadolinium Page 33 of 36

34 Fig. 28: 5 old boy with posterior ankle pain and fever. Acute osteomyelitis, MRI shows intra spongeous oedema and bony changes in the calcaneus with low signal intensity on T1 weighted images, elevated signal on STIR and enhancement after gadolinium Fig. 29: 26 old woman presenting posterior ankle pain with ankle swelling US shows hypoechoic soft tissue mass near the FHL tendon, with increased Doppler signal Page 34 of 36

35 Fig. 30: Sagittal T1 (A), DP FATSAT (B)and T1 Gado showing heterogenous mass in the posterior and medial aspect of the ankle enhanced by gadolinium administration After percutaneous biopsy, pathological examination demonstrate a synovial sarcoma Page 35 of 36

36 Conclusion Many potential etiologies of hind-foot pain, including both soft tissue and osseous abnormalities Posterior ankle impingement is the most common cause of posterior ankle pain, in athletes Initial evaluation should always include plain radiographs Ultrasound and MR imaging are the best modalities for optimal detection of most softtissue disorders of the tendons, ligaments, and other soft-tissue structures of the ankle and foot MRI is also valuable in the early detection and assessment of a variety of osseous abnormalities seen in this anatomic location Personal information Department of Radiology EL KASSAB ORTHOPEDIC INSTITUTE- TUNIS References 1/Rocky S., Stacy R, Juliann G, Daniel K.MRI of Ankle and Hindfoot Pain. Am Osteopath Coll Radiol 2015; Vol. 4, Issue 2 2/Blakemore LC, Cooperman DR, Thompson GH. The rigid flatfoot. Tarsal coalitions. Clin Podiatr Med Surg Jul. 17(3): / Koulouris G et al. Foot and Ankle Disorders: Radiographic Signs. Seminars of Roentgenology. 4/ Zehava S. MR Imaging of the Ankle and Foot. Radiographics Page 36 of 36